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What Is Included in a Comprehensive Mental Health Assessment?

When patients are concerned about a behavioral health issue, one of the first recommended steps is to talk to a healthcare professional. Whether it's a primary care doctor or a behavioral health specialist like a psychologist, the practitioner may conduct a comprehensive mental health assessment, sometimes referred to as a behavioral health assessment or behavioral health clinical assessment. Such an assessment can help identify behavioral health problems and assist the practitioner in figuring out the best way to address them.

What is a Behavioral Health Assessment?

A behavioral health assessment is designed to provide a doctor with a more complete picture of the way a patient thinks, feels, reasons, and remembers. It may be used to help providers: 

  • Diagnose behavioral health conditions such as anxiety, depression, schizophrenia, and eating disorders 
  • Evaluate cognitive disorders, such as dementia 
  • Identify developmental problems, such as learning disabilities and autism spectrum disorders 
  • Differentiate between behavioral and physical health problems 
  • Assess a person referred because of problems at school, work, or home 

As we will discuss in the next section, comprehensive mental health assessments typically consist of an interview, physical examination, written questionnaires, and lab tests. However, the particular tools used and the approach taken may vary with the individual being assessed.  Unlike some mental health assessments for adults, behavioral health tests for children will depend on their age and might include asking them to draw pictures to help express their feelings. Other types of mental health assessments may be specifically geared toward adults over 60 years old to help identify depression and cognitive impairment. 
An initial behavioral health assessment may be followed by additional, more specific tests. The most recent version of the “Diagnostic and Statistical Manual of Behavioral Disorders (DSM Version 5)” lists more than 150 diagnoses. Some of these can be challenging to diagnose, especially for healthcare providers who are not behavioral health specialists, so further assessments may be necessary to refine a diagnosis.

Download the eBook The Guide to Behavioral Health Assessment Software:  Improving Assessments & Patient Outcomes here.

Components of a Behavioral Health Clinical Assessment

Most types of mental health assessments contain similar basic components, although the specifics may be changed depending on the individual being assessed, the clinician doing the assessment, and the place where the assessment takes place. 
Typically, a behavioral health assessment will consist of the following:

1)  Interview

A doctor asks patients questions about their symptoms and concerns. These questions may cover personal or family history of behavioral health issues; lifestyle and personal history, including any sources of stress or trauma; and current thoughts, feelings, and behaviors. During the interview, the practitioner may also make note of a patient's appearance and behavior for clues to explain the patient’s symptoms. 

The approach taken for verbal interviews should not only take into consideration a patient's age but many other factors, including social determinants of health (SDOH). SDOH can be defined as "… conditions in the places where people live, learn, work and play that affect a wide range of health and quality-of-life risks and outcomes." 

Concerning the effect of SDOH on behavioral health, the federal government's Healthy People 2030 initiative notes, "Several factors have been linked to behavioral health, including race and ethnicity, gender, age, income level, education level, sexual orientation, and geographic location. Other social conditions — such as interpersonal, family, and community dynamics; housing quality; social support; employment opportunities; and work and school conditions — can also influence behavioral health risk and outcomes, both positively and negatively. … A better understanding of these factors, how they interact and their impact is key to improving and maintaining the behavioral health of all Americans."

2)  Physical Exam

 A patient may receive a physical exam to help exclude physical causes, such as a neurologic problem, or behavioral health issues. In addition to the exam, a doctor may ask the patient about their general health history, any medications or supplements taken, family health history, and drug and alcohol use.

3)  Lab Tests

Since some physical conditions can present similar symptoms as behavioral disorders, a doctor may recommend that a patient undergo lab tests. These may include blood or urine tests to rule out anemia, a vitamin deficiency, or a thyroid disorder. If a doctor suspects a patient has a nervous system problem, they may undergo tests such as magnetic resonance imaging (MRI) or electroencephalogram (EEG).

4)  Written Questionnaires   

A doctor may ask a patient to complete a written mental health assessment questionnaire or verbal test to assess specific problems, such as depression; how well a patient can think, reason, and remember; or how well the patient can carry out activities of daily living, such as caring for oneself and going to work.

Understanding Different Types of Mental Health Assessments

There are many different kinds of behavioral health questionnaires and assessments that clinicians can administer to their patients. The choice of mental health assessment questionnaires used may depend on the age of the patient, the patient’s symptoms, and even the background of the clinician. 
Below are some examples of commonly used behavioral health questionnaires: 

  • Patient Health Questionnaire (PHQ9): used to screen for symptoms of depression 
  • General Anxiety Disorder 7 (GAD7): used to screen for symptoms of anxiety 
  • Columbia Suicide Severity Rating Scale (C-SSRS): used to assess suicide risk 
  • General Practitioner Assessment of Cognition (GPCOG): used to screen for cognitive impairment in primary care settings 
  • Vineland Adaptive Behavior Scales: used for diagnosing and classifying disorders such as autism spectrum disorder and developmental delays in children 
  • Mini-International Neuropsychiatric Interview (M.I.N.I.): a structured interview to help diagnose the most common psychiatric disorders in adults and children

To strengthen how your organization uses behavioral health assessments and questionnaires to take actions that can further improve patients’ mental health, reach out to Proem. Our evidence-based behavioral health workflow uses a single tool to assess multiple conditions. Electronic behavioral health assessments and treatment processes are configurable within an organization’s existing workflows, thus helping providers to more accurately and efficiently screen, diagnose, treat and monitor their patients.

The Guide to Behavioral Health Assessment Software: Improving Assessments & Patient Outcomes

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